Information Collection

Request For Review Part B Medicare Claim

IC 157642 under ICR 198003-3220-005 · OMB 3220-0100.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0100 can be found here:

Documents and Forms

Document Name Document Type

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Information Collection (IC) Details

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IC Title:	REQUEST FOR REVIEW PART B MEDICARE CLAIM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-790				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,100	100	4,000
Annual IC Time Burden (Hours)	1,025	25	1,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.